CEimpact Podcast

Supportive Care for Patients with Cancer

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Discover how pharmacists can play a pivotal role in improving the quality of life for patients with cancer through supportive care interventions. This episode explores practical strategies for managing side effects, enhancing adherence, and addressing the unique needs of oncology patients. Don’t miss this chance to expand your impact—listen now and learn how to provide compassionate, evidence-based care to your patients.

HOST
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact

GUEST
Olivia Fahey, PharmD, BCOP
Cancer Care Education Pharmacist
The University of Kansas Cancer Center

Reference
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CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1.  Describe common supportive care needs for patients with cancer, including management of side effects and comorbidities.
2. Identify evidence-based strategies pharmacists can use to enhance medication adherence and improve the overall quality of life for patients with cancer.

0.05 CEU/0.5 Hr
UAN: 0107-0000-25-021-H01-P
Initial release date: X/X/2024
Expiration date: X/X/2025
Additional CPE details can be found here.


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Speaker 1:

Hey, CE Impact subscribers, welcome to the Game Changers Clinical Conversations podcast. I'm your host, Josh Kinsey, and as always, I'm super excited about our conversation today. Cancer is not just a diagnosis. It's a life-altering experience that brings physical, emotional and financial challenges. Treatment alone is not enough. Patients need comprehensive support to navigate side effects, maintain their quality of life and feel truly cared for. In today's episode, we'll explore how pharmacists can play a vital role in providing this much needed supportive care and making a meaningful difference in their lives. It's so great to have our guest expert for today, Olivia Fahey. Welcome. Thanks for being here, Olivia Fahey.

Speaker 2:

Yes, thank you so much for having me. I'm very excited to be here.

Speaker 1:

Yes, and a little history. So for our learners out there, obviously you're not going to know this, probably, but my husband used to work with Olivia at the University of Kansas, so I have the pleasure of knowing her personally and it's so great to have you here. I just really appreciate you taking time out for this episode.

Speaker 2:

I'm very excited to be here and talking about supportive care, which is something I spend a lot of my time talking about Exactly exactly so for our learners.

Speaker 1:

Livia, it's going to be the first time for some of them to meet you, so if you'll just take a few minutes to tell us a little about yourself, your practice site and maybe kind of why you're passionate about oncology, yeah, so, as you mentioned, your husband and I previously worked together.

Speaker 2:

So we started at the University of Kansas together, where I work at our cancer center, primarily in our breast medical oncology and our gynecologic oncology offices, so seeing patients with breast cancers and then like ovarian, cervical and uterine cancers primarily ovarian cervical and uterine cancers primarily. And prior to starting here, I did my PGY1 and PGY2 residencies at UW Health in Madison, wisconsin, and I graduated from University of Wisconsin School of Pharmacy.

Speaker 1:

Awesome, awesome. What made you go into oncology? What was kind of that pathway for you?

Speaker 2:

Yeah, and so really it was when I was a student pharmacist. During my fourth year I did an oncology rotation in an oncology clinic and as a student and not someone that was really oncology trained I spent a lot of time counseling patients and following up on them, specifically on supportive care. You know we have really great cancer treatments but a lot of those treatments are really toxic and require sometimes really significant supportive care medications. So I spent a lot of time counseling patients on how to take their antiemetics and how to manage their bowels and those sorts of things and seeing the role that pharmacists were able to play in helping to support patients through these really difficult treatments and these really difficult treatments and just really interesting treatments we get lots of. You know we're always getting new treatments and new medications and you know kind of sometimes really complicated treatments and complicated regimens.

Speaker 1:

So really, just a huge and complicated side effects too, I know, I've heard of some of the things that Kel's talked about in the past, and I'm always just like that's a side effect. That sounds terrifying.

Speaker 2:

So just kind of seeing the role that my preceptors were able to play, I was like, yeah, that's, that's what I want to do. So that's why I did residency and came and started this job here.

Speaker 1:

That's great, that's great. Well, thanks again for joining us. We really appreciate it. And I'd like to just jump right into our content for today, just to kind of um set the stage. So just as um for those that may not fully know, when we say supportive care, supportive oncology care, like what exactly does that mean, like what does that entail, and kind of where does pharmacy come in there?

Speaker 2:

so yeah, I usually consider anything supportive care, supportive care, supportive care medications as any of the medications that we kind of give in conjunction or as needed around a cancer treatment. So classically you think of something like cisplatin, a traditional chemotherapy that is highly immunogenic and actually has nausea and vomiting as a dose, limiting toxicity and giving pre-medications or anti-emetics to help kind of prevent nausea from happening or preventing patients from vomiting after treatment. But as our treatments have expanded, we've had, you know, different kinds of supportive medications that we have to give as well.

Speaker 1:

Yeah, yeah, I think that would be the one that I would have immediately known. If somebody would have been like what's one of the most common meds that you give to a patient with cancer? You know, I would just say the anti-medics. But what are some of the other medications that we might be on the lookout for in different practice settings? Like if we see something and think, oh, that's probably supportive care and maybe a few extra steps there.

Speaker 2:

Yeah, I think the other thing too is we can also see a lot of skin changes and rashes, so sometimes we're using topical steroids or even topical antibiotics to help even prevent the formation of acne form rashes, especially from our agents that are targeting that EGFR pathway.

Speaker 1:

Okay.

Speaker 2:

And especially since those are like an acne, like rash, but are treated very differently than acne. Of course we always are thinking about like anti-infective prophylaxis, especially in patients on more of our hematologic conditions or hematologic malignancy treatments or bone marrow transplant, where you know they're needing antibacterial or antiviral prophylaxis to support them during.

Speaker 1:

Because their immune system is so weak in that time. So yeah, yeah, okay, okay, yeah, that's great. So in the care of patients with cancer in general, there's a lot of moving parts. So if let's say you're not a pharmacist, that's a BCOP or a specialist in oncology care, where does pharmacy fit in that multidisciplinary team? Where can we plug in?

Speaker 2:

really pharmacists can be involved in kind of every aspect of care and every phase of care. So especially, you know I live in Kansas City. I work at a large, you know quaternary hospital. We're one of the only comprehensive cancer centers in our state. So we have patients coming from all over Kansas, missouri and even beyond to come to our treatment and especially if they're on treatment, that's you know, every couple of weeks they, you know, are coming here and then they're going home and spending time, you know, back in their home communities and you know might be needing to pick up prescriptions from their pharmacy or if they're dealing with bowel changes or constipation or diarrhea.

Speaker 2:

Really those are one of the things that can be really most impactful and that I spend a lot of time talking about. That I feel like people kind of forget how important that is. But a lot of our antiemetics can, you know, their serotonin antagonist, so they can slow the GI motility and can have a constipating effect very similar to opioids, and then a lot of times if patients get constipated, then that can make their nausea worse as well.

Speaker 1:

Wow, this is a vicious cycle.

Speaker 2:

Yes, so really helping patients to navigate those over-the-counter options for constipation as well, and making sure that they're thinking about it, pushing fluids and that sort of thing If they're using Miralax, that sort of thing.

Speaker 1:

Yeah, and I think it's. You know it's super important to think about too, that you know those are kind of quote unquote taboo subjects and not all patients are going to just freely talk about, you know, the bowel movements or whatever with you. And so that you know it's important, I think, to make sure that we're asking those right questions and that we're educating, because they also may not fully realize that, oh, this is a side effect of the anti-medic, or this is because of this drug, you know, or whatever.

Speaker 1:

So for sure, yeah, yeah, we've talked a little bit about some of the medications and some of the things that we're managing, you know, in this supportive care space. So we've talked about nausea, we've talked about the GI issues that may be coming as well. What about, like, pain and emotional distress, like, are those often things that we see in that, in that supportive care space as well?

Speaker 2:

No for sure, Pain is a huge thing. That you know. For cancer pain or cancer treatment related pain I'm certainly not an expert is because I really primarily work with medical oncologists or gynecologic oncologists. But radiation can be very painful. Of course, surgery can be painful and one of the things that I see a lot concerning pain is a lot of my patients are in really severe pain and they're just terrified to take opioids and have you know there's been you know, exactly, and there's lots of you know, lots of news coverage, and just the opioid epidemic has been something that has really been heavily covered.

Speaker 2:

We certainly have heavily overused opioids in our country in the past or more kind of inappropriately utilize them, but I spend a lot of my time, you know, educating patients that you know opioids truly are one of the best treatments for cancer related pain and that's what they were initially studied and used for and are appropriate, and kind of reassuring them that if they're using it appropriately for cancer related pain, we really don't see concerns of abuse or that dependence there, but making sure and again, education is key, like talking about that with them, educating them that we're going to be along the process with you, we're going to be monitoring you, we're going to make sure you're taking it correctly, in the right doses, and everything.

Speaker 1:

So and then yeah, and then you know if we're adding in pain medication. That's a whole nother issue with potential constipation again. So just right back to that cycle where other things are going to are going to play off of you know another drug. It's going to cause something else, so yeah.

Speaker 2:

And certainly to a different long acting and short acting regimens, and keeping track of those and using the break You're there as needed for breakthrough pain and all that sort of thing is certainly something pharmacists can really help patients, and also just schedule and Exactly and just education as well on.

Speaker 1:

Okay, so let's say you're on medication that has a combo, acetaminophen, and then you get a cold and you're taking something over the counter, like discussing the fact that you know we don't want to get too much acetaminophen. What's your current dose daily right now and you know that kind of thing. So, again, lots of ways that pharmacists can really plug in in this space. You don't have to even know anything about cancer meds, really, because it's all about the support in some of these things. So yeah, and I touched on this, but I'll go back to it, Is there anything in like the emotional distress space? Like, do we see a lot of antidepressants or anti-anxiety meds and things?

Speaker 1:

like that that are also yes co-prescribed.

Speaker 2:

Certainly you know, cancer diagnosis and undergoing cancer treatment can be certainly extremely upsetting for patients and it is very common that we do end up adding or starting new antidepressants or anti-anxiety medicines. Diloxetine we really love because in addition to helping, you know, with mood and anxiety, it can help with some neuropathic pain. Yeah, that's right.

Speaker 2:

Yeah we're really quick to offer that. You know that's really in our arsenal or something we're thinking of a lot if patients are expressing that, and then in the breast cancer population that I work with, a lot of these patients, especially our younger ones, are being very abruptly sent into menopause especially our younger ones are being very abruptly sent into menopause and so lots of changes with that in mood or emotional ability or just mood regulation and things like that.

Speaker 2:

We often sometimes find that adding in an SSRI or something like that can be really helpful for that or hot flashes and that sort of thing as well.

Speaker 1:

Yeah, interesting. We have a course on hormone imbalances because of menopause, and so I just learned a whole lot of new stuff about that. We had a podcast on that recently, so listeners out there, if that interests you, jump onto that segue. But yeah, it's something I didn't even think of because you're messing with the hormone balance in these patients, and so, yeah, wow, okay, very interesting. What about? In many cases, patients with cancer also have comorbidities as well.

Speaker 1:

So, we also, just in general, have our typical diabetes hypertension, you know, and even some of the other medications that they're on, maybe for chemo, is causing increased heart rate or increased blood pressure or things like that. So can you speak just a little bit about some of those things to keep in mind as?

Speaker 2:

well, yeah, absolutely. One thing when thinking about diabetes is we use dexamethasone and some other steroids too, but especially dexamethasone for a whole host of reasons. We use it for anti-emetic a lot, we use it to help prevent infusion reactions. We use it to help prevent swelling or skin changes from chemotherapy medications. So one thing I'm counseling patients on a lot is if they do have diabetes and we're taking dexamethasone and starting it especially sometimes these patients are taking dexamethasone for two or three days after treatment to make sure that they are watching their blood sugars, that if they are someone that is on insulin before starting these medicines, that they're kind of really aware and checking that and have a good plan with their diabetes manager going into treatment so that they are aware of that. And we also have some of our more targeted therapies that can cause hyperglycemia as an on-target effect of some of our PI3 kinase alpha inhibitors.

Speaker 1:

Interesting. And another thing, you know I was trying to just kind of put in the pieces, you know, just also stress in in general we know can affect glucose control and so the stress of having a diagnosis or the stress of going through chemo as well as nutrition changes.

Speaker 2:

Yes, those, are the same yeah, yeah, if they're not hungry or they can't eat what they normally would eat. Yep, we certainly can see a lot of changes. And then, in terms of hypertensive or hypertension, we can see some some of our cancer treatments that target our VEGF pathway and our anti-VEGF inhibitors. Our VEGF inhibitors can also cause drug induced hypertension, so sometimes we're adding or increasing or starting new blood pressure medications.

Speaker 1:

Wow, yeah, so again it's. You know it's not as simple as you know they're on a chemo agent. It could be that other things are added. Other things are in support and added Other things are causing other things which cause something else to be added. So, yeah, that's why this topic is so needed to talk about, because it's just it's so complex and our patients need that support.

Speaker 2:

Yes, it can get very complicated very quickly. I do a lot of patient education for patients starting chemotherapy, and usually I'm talking about five to 10, as needed or even scheduled, supportive care medications in addition to, you know, their sometimes several chemotherapy medications. So I think another thing, too that maybe some of their non-expert pharmacists can help with, too, is just helping to remind patients of what each medication is for or when they should be using things, because it can be a lot of information information all at once that you're like, oh yeah, that makes sense.

Speaker 2:

But then you know that day when you're acutely having diarrhea or you're not feeling well, having someone to kind of help point you in that right direction or remind you of the directions.

Speaker 1:

Absolutely. Yeah, I mean just in general. I feel like even when I go to the doctor for an update and they tell me something and then like a in general, I feel like even when I go to the doctor for an update and they tell me something and then like a week later, I'm like what was it they said again? You know, like I can't even imagine dealing with the anxiety of a new diagnosis and all of these new things being thrown at me and then having, you know, expecting myself to like remember certain things. So, yeah, another great opportunity for pharmacists there is to really be just the medication expert which we are already, and just providing that support. So, yeah, so we've talked about opportunities for pharmacists in this space. Obviously we're, with this support, with this education, with sharing of this information, watching out for certain things, asking the right questions, we're increasing and enhancing a patient's quality of life. Have you seen pharmacists also in this space being able to help improve treatment adherence?

Speaker 2:

because of education oh for sure, because, especially if a patient's on a treatment that causes really horrible diarrhea and then they get dehydrated and they're having electrolyte issues and they get admitted because they didn't realize or they weren't taking their loperamide correctly, or if they have horrible nausea that they can't control, certainly those things can cause patients to have to delay or interrupt or even have dose reductions or stopping of certain treatments. So that's why we do such a big emphasis on making sure we're appropriately pre-treating patients and making sure that they have the medications that they need to be there so that we're able to make the treatments that they're receiving more tolerable and able to successfully receive those treatments and then stay on them longer, right.

Speaker 1:

So that they can actually have an impact on the overall goal, which is to get rid of the cancer. So yeah, yes.

Speaker 1:

Yeah, and so obviously you touched on that as well, how the pharmacist role can also reduce hospitalizations and just in general reduce those readmissions. Because again, if a patient knows every time I do this and take this medication, it causes diarrhea, so I need to be sure that I'm taking fluids, I'm taking my loperamide, whatever, then we're not going to get dehydrated, we're not going to get readmitted, we're not going to have to go in for supportive care in that way.

Speaker 2:

So yeah, Exactly so that they can better try and prevent or start to treat any symptoms early, so that they don't get out of hand.

Speaker 1:

Exactly, exactly. So. We've talked, then, about some of the opportunities that pharmacists have in this space. So what are some of the challenges that we're going to see? So let's say that we're an AmCare pharmacist or a community pharmacist and we're not really in the inpatient setting and we're not in an oncology specific setting. What are some of the challenges that we might see if we're trying to really provide the supportive care to these patients?

Speaker 2:

Yeah, I think one of the challenges is not having that familiarity with the treatments or not knowing what the treatments are or the associated ones, like what the best supportive care is. One of the things I had mentioned was we can see like an acne form rash from our EGFR inhibitors. I had mentioned was we can see like an acne form rash from our EGFR inhibitors. So it looks like acne, but really moisture and moisturizing can help to prevent and treat that rash. So if you used traditional anti-acne products, a lot of those can be really drying and irritating and actually exacerbate that.

Speaker 2:

So not having that understanding, and then also if it is where they're not as involved or don't have that close communication with their oncology provider's office and just not always having the full picture or the full information.

Speaker 1:

Not being able to know.

Speaker 2:

Exactly, especially with a lot of our treatments being oral and our oral chemotherapies or our oral targeted therapies, a lot of those patients are required to fill with specialty pharmacies that might not have the full medication list, or we at our community pharmacists might not have that full picture of their medication list too. So really, just kind of the fractured information can certainly be a challenge. Just kind of the fractured information can certainly be a challenge, especially if you're working with a patient that isn't as familiar or doesn't remember everything that I was talking about.

Speaker 2:

It's hard to get that, to make all those connections, yeah, so.

Speaker 1:

I think it's really important, then, for pharmacists in that role to be sure that we are A staying up to date on medications, educating ourselves so that we can share that information and be aware of certain side effects, like you mentioned with the rash and so forth, but also, you know, when you find out that one of your patients is going through cancer treatment, making sure that you know all the medications they're on, Because, again, don't just assume well, they're just on the ones that I'm filling. It could be that they're on other things and it might even be that it's, you know, the specialty pharmacy is filling one of the supportive care and you didn't even realize that they had this one or something. So I think, yeah, so it's really the onus is on the pharmacist to be sure that we are staying up to date and really kind of making those connections.

Speaker 2:

And I think always thinking about clinic and interstitial infused medications as well, I think we're always thinking about prescriptions and medications filled under the prescription benefit.

Speaker 2:

But you know, certainly I think if people are aware that patients are on cancer treatment and thinking about that, they're kind of thinking about that. But you know, always keeping that in mind as well, because they also might be on, you know, supportive care medications to help with their bone strength, like our denosumabs or zolangionic acids and that sort of thing where we can see electrolyte abnormalities or like symptoms, with our bisphosphonates. That sort of thing.

Speaker 1:

Yeah, so you bring up another great point there. It may not even be something that's being quote unquote filled in a pharmacy, and so just also again asking the right questions, making sure that you're in the know what all is this patient being treated with and you know from what practice side. So, yeah, that's great.

Speaker 2:

This also reminds me one of the things everyone always thinks about on Dantotron or Zofran as an anti-emetic. But for our more higher risk treatments of having nausea, a lot of times we'll give Palinocetron or the subcutaneous Granisotron as a prophylactic anti-emetic, and these have half-lives of days, and so one of the things I spend a lot of time telling my patients and educating my patients on is making sure that they're reaching for their proclorperazines or their other anti-emetic medications, especially in those first couple of times, since If they're on that long-acting, if they're already on those long-acting serotonin antagonists.

Speaker 1:

Because, like you mentioned too much of that hitting the serotonin pathway, we might have GI distress and constipation and other issues. Exactly.

Speaker 2:

And a lot of times it just doesn't help very much. If you know, the palinocytron is still in there blocking those pathways.

Speaker 1:

So if they're feeling nauseous we kind of got to go for a different path, hit it a different way yeah, hit it in a different angle. Yeah, that's great, okay. So I think we touched on most of the challenges that I kind of wanted to cover, and that's just making sure that we're navigating the treatment regimens, that we're staying up to date ourselves as pharmacists, making sure that we know what's going on with our patients so that we can help support them. And then also, just in general, staying and again, especially if you have a longtime patient that now has cancer and you're supporting them because you've been, you know, taking care of them for 20 years, it might be good to brush up on the guidelines for whatever it is that they're going through.

Speaker 2:

So that again you can be have to create an account to access them. But they have guidelines on some of the supportive care medications. For nausea they also have anti-infective prophylaxis and then also for growth factors.

Speaker 1:

Wow, that's great. So tell us that organization again, olivia.

Speaker 2:

Yeah, nccn or the National Comprehensive Cancer Network.

Speaker 1:

That's great, that's great, and I think our website's nccnorg.

Speaker 1:

Perfect. Yeah, that's awesome. So in our last few minutes here, as we're wrapping up, just if we're a pharmacist and one of our listeners is out there trying to be like how can I do this, how can I slowly implement the supportive system within you know, normal workflow or whatever? Like what are? What would you say are like three or four things? Be sure you do this, be sure you ask this. Like, would you be able to summarize that? Just to give our learners something to kind of walk away from with today?

Speaker 2:

Yeah, I think the key things are making sure that the patient understands what each medication is for and how to take them, so making sure that they have a way of assessing that with each patient. And then I think the kind of thing one of the things we talked about at the beginning is making sure patients are having regular bowel movements or have a handle on that, or helping to assist if they're having constipation or diarrhea, since we can really see either with the treatment and then also making sure we have that full picture of all the medications, all medications, and not just the full picture, but also, you know, are they on this new antihypertensive because of, you know, the blood pressure increasing because of this med?

Speaker 1:

like understanding why they're on certain medications again so that we can provide the right education.

Speaker 2:

And so then also we can make sure we're taking those off or stopping them once they change treatments or finish treatment and stuff like that, making sure we're considering like, oh, do we need to maybe back off on this now or that Great point.

Speaker 1:

Yeah, that's great. Well, I always am just wowed at how quickly time goes when I'm in these conversations, because I just always feel like I'm learning so much and the time just flies and we're getting close to the end of our time for today. Is there anything that we missed? Is there anything that you're like? I really want learners to know this in this space.

Speaker 2:

Yeah, the only other thing I think that we haven't really talked about is I we also do a lot of growth factor support, um and our granulocyte colony stimulating factors to help, you know, reduce the risk of febrile neutropenia and increase those white blood cells. A lot of times patients are having to self-administer those at home and especially if they're daily making sure they're comfortable with subcutaneous administration and then they can cause a lot of bone pain or fullness. So making sure patients are comfortable from that so that they're able to receive these really important medications. Supportive care for the supportive care medications.

Speaker 2:

Some of our anti or typical or NSAIDs are acetaminophen to help with pain and there's some mixed data on antihistamines like loratadine. But certainly it's also a pretty low risk intervention to try and help prevent some of that bone pain.

Speaker 1:

Yeah, that's a great call out to Olivia is to make sure that the patients are a familiar with the proper technique for subcutaneous injection and are comfortable with it, because some people have extreme needle phobia.

Speaker 1:

And it reminds me. I always try to connect back to other courses that we have in the catalog, and we do have a course on information to use when educating a patient on proper technique for at home oh, wonderful, and so I think that that would be something for our learners out there too to look up. And because, again, you want to be sure that they're getting their needles refilled regularly, because you're supposed to use a new needle with each injection and things like that. So, just and sharps containers Exactly, having a sharps container. So a lot of information, and that's all covered in that course. So that's an another great way for our pharmacist to kind of prepare to better support patients with cancer. So, yeah, that's great. Well, olivia, last thing I always like to do before we wrap up is just kind of bring it back to what's the game changer here? What do you want our learners to leave with today? If they leave with one thing, what would be the game changer here for our listeners?

Speaker 2:

Yeah, I think really that the game changer is helping patients with their over-the-counter medications, especially with the bowel regimen.

Speaker 1:

Yeah, yeah, I think that's one of the big things that we've talked about many times already in just the short episode, so it seems like it's a really important part of that supportive care.

Speaker 2:

And really has a really big impact on people's quality of life, and it's not maybe the sexiest thing or something people always want to talk about, but that is really why our pharmacists should be thinking about it and asking our patients about it to help them with it.

Speaker 1:

Yeah, and again, like we said, it's probably not something they're going to voluntarily talk about with you. So you're going to have to ask those questions make sure they're open-ended questions so that you get full answers back from your patients, so that you really get a big picture of what's going on. So, yeah, it's great. Well, that's all we have time for this week. Thank you so much again, olivia. It was great having you on the episode today. I really appreciate your time.

Speaker 2:

Yeah, thanks for the invite.

Speaker 1:

Of course, if you are a CE Plan subscriber, be sure to claim your CE credit for this episode of Game Changers by logging in at CEimpactcom. And, as always, have a great week and keep learning. I can't wait to dig into another game-changing topic with you all next week. Until next time.